PACIFIC NORTHWEST UNIVERSITY OF HEALTH SCIENCES - REPORT OF INJURY
EMPLOYEE/STUDENT INFORMATION
Date of Incident
Employee/Student Number
Employee/Student Name
First Name
Last Name
Department
Supervisor's name
Supervisor's Phone Number
ACCIDENT INFORMATION
Injury Time
Time Work Began
Date University Notified
Last Work Date
Date Returned To Work
Date Coordinator Notified
Location and Zip Code
Premises Yes/No
Please Select
YES
NO
Incident Type (slip, fall, sprain, etc)
Body Part (specify right, left, 1st, 2nd, etc)
Cause of Injury/Illness (description)
Employee/Student's Activity (What was the Employee/Student doing?)
Equipment, Materials in Use
Witness Name
Witness Phone Number
Witness Name
Witness Phone Number
Safeguards Used Yes/No
Please Select
YES
NO
Safeguards Provided Yes/No
Please Select
YES
NO
MEDICAL TREATMENT
Initial Treatment 1, Minor: by Employer 0; No Medical Treatment 2; Minor Clinic Hospital 4; Hosptialized > 24 hours 3; Emergency Case 5; Future Major Medical Lost Time Anticipated:
Name of Physician, Clinic or Hospital
Report Completed by
Date:
Submit
Report Follow up - FOR INTERNAL USE ONLY - not viewable by submitter
Should be Empty: